� 1 Governor’s Council on Health Care Innovation Update for the Montana Medical Association March 2016
Governor’s Council on Health Care Innovation and Reform � 2 Governor Bullock appointed an advisory council of private and public payers, providers, regulators, and patient advocates to guide the development of Montana’s statewide health transformation plan. Charge 1. Identify opportunities to improve care delivery and control costs in Montana’s healthcare system 2. Explore opportunities to coordinate between public and private sectors to improve health system performance and population health GOAL: Obtain consensus among public and private stakeholders – payers and providers – to implement one or more delivery system models and accompanying value-based payment methodologies to advance the triple aim in Montana of improved patient experience, improved population health, and reduced costs
Governor’s Council Themes � 3 Takeaway: Stakeholders want to be part of the change and need a common agenda Initial Issues to be Addressed 1. Physical and behavioral health integration, including substance use, chemical dependency and mental health integration 2. Social determinants of health and disparities among American Indians and other populations 3. Health information exchange (HIE) and telehealth Challenges Opportunities & Solutions • Workforce • Health IT services and workforce initiatives: • Administrative claims data • Rural nature of the state � limited aggregation access to care • Telehealth • Lack of comprehensive patient data • Health information exchange • Project ECHO • Integration of direct patient service • PCMH, Health Homes, ACOs and environment and public health Collaborative Care Teams services • Greater alignment: public and private • Limited funding for new initiatives sectors • Fee-for-service payment • Alternative, value-based payment models environment
Delivery Model Principles – For Discussion � 4 As the Council considers and evaluates delivery models, it should assess the extent to which each model supports a set of core principles Simple and Data-driven Patient- flexible for and centered providers to measurable rollout Sustainable Replicable for and tied to Scalable different payment conditions reform Collaborative Multipayer
Delivery System Model Development Framework � 5 Key Elements • Data Working Group findings • Target populations and Define objectives and target population(s) conditions Return on investment (ROI) • Consider potential impacts Scalability and sustainability • of delivery reform models Measures • • Care model definition Define core elements of delivery models • Existing resources • Funding sources Develop supportive payment models • Payer commitment • Value-based payment • Stakeholder commitment Implement • Work plan • Evaluation and refinement
PCMH as a Foundation for Reform � 6 Montana’s existing PCMH program should serve as the foundation for participating providers PCMH Stakeholder Council Montana Insurance Commissioner Blue Cross Blue Montana Medicaid PacificSource Allegiance Shield • PMPM preventive • PMPM to support • PMPM participation Payment for care and participation PCMH infrastructure fee coordination (using fee • Grant-based funding • PMPM fee for disease CPT codes) for • PMPM fees for • Shared savings/ mgmt members identified disease management quality bonuses for • PMPY fee for by the payer as high performance achieving quality risk benchmarks PCMH Practices PacificSource Allegiance Medicaid Members BCBS Members Members Members Confidential Working Draft – Not for Distribution
PCMH as a Foundation for Reform � 7 Participants 2014 At-a-Glance • Participating clinics must: o Submit a Comprehensive Application • 70 PCMHs participated o Be accredited by one of three national accrediting agencies • Popular elements of practice o Report on 3 out of 4 quality of care metrics transformation included: o Same day appointments Governance o Patient portals • The Insurance Commissioner and a 15-member o Clinical advice outside of office PCMH Stakeholder Council consulting on program hours decisions Quality • Initial quality results are promising o Rates of hypertension, diabetes, • PCMHs must report on four quality measures: and tobacco use were close to blood pressure control, diabetes control, tobacco or lower than national and cessation, and childhood immunizations Montana targets • Depression screening will be added to the o Several childhood program’s quality measures for 2016 immunizations met national o For the 2016 measurement year, PCMH’s will targets report on 4 out of 5 quality measures
Evidence for PCMHs � 8 T he most recent evidence on PCMHs, including more than 30 published studies and evaluations, points to clear trends in reduced costs and utilization, and improved quality. PCMHs are designed to provide a strong foundation for delivery system and payment reform. Reduced Utilization and Improved Outcomes Costs ✓ Recent studies have found: ✓ Recent studies have found reductions in ED visits, hospitalizations, specialty visits, prescription drug • Better quality of care for use and related costs diabetes, vascular, asthma, depression, kidney disease, and ✓ By year 3, most programs see cost reductions: hypertension • Geisinger Health System saved $53 PMPM • Higher rates of cancer and (others cited PMPM savings of $9-40) substance abuse screening • BCBS Rhode Island PCMH program had ROI of 250% • Improved measures of patient experience, including access to • Minnesota multi-payer PCMH program saved an care, doctor rating, and continuity estimated $1 billion over 4 years of care o Nearly all Medicaid savings • Physician support for program and o Driven by reductions in hospital visits augmented services
Delivery System Models – Building on the PCMH Foundation � 9 Collaborative Care Model Hot-Spotting with (Could be Echo-Enhanced) Community Resource Teams PCMH PCMH PCP Health CHW Coaches Patient Community Resources RN BH Consultan t
Spotlight on Evidence/ROI for Collaborative Care � 10 The Collaborative Care Model has been tested in more than 70 randomized controlled trials in diverse settings, with different provider types and patient populations. The model is recognized as strongly evidence-based. Positive Health Return on Investment: Impacts: ✓ More effective than usual care across ✓ Largest study: ROI of $6.50 for diverse populations for range of mental each dollar spent health conditions ✓ Net savings in every category of ✓ Demonstrated improvement in health health care costs examined: disparities in low-income, ethnic minority • Pharmacy populations • Inpatient and outpatient ✓ Strong endorsement from patients, medical primary care providers, and psychiatrists • Mental health • Specialty care https://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/ Downloads/HH-IRC-Collaborative-5-13.pdf
Spotlight on Evidence/ROI for Project ECHO � 11 “Project ECHO expands access to best-practice care for underserved populations, builds communities of practice to enhance the professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.” – Health Affairs Study Positive Impacts for Patients and Providers: Return on Investment: ✓ As safe and effective as usual care ✓ Hub costs estimated about ✓ Increases number of patients treated by $300,000 per year – first hub specialists (expanding workforce) launched in Billings ✓ Increases access in rural areas ✓ Free technology works with laptop, webcam, tablet, smart ✓ Improves physician-reported measures of phone knowledge, skills, professional satisfaction, practice recognition ✓ Expands ROI/reach of other proven models (e.g. ✓ Promotes provider retention in rural and Collaborative Care) underserved communities
Spotlight on Evidence/ROI for Hotspotting � 12 Camden Coalition model, on which the Mountain-Pacific model is based, is widely recognized as a promising model for a selection of the highest cost, highest need patients fitting into a patient typology. The first randomized control trial evaluating the model is underway. Positive Health Impacts: Return on Investment: ✓ Increases security, genuineness, continuity of ✓ Camden model reduced ED care visits by 40% for the first 36 ✓ Associated with improved patient motivation and patients, and costs dropped by active health management and improved patient 60% perception of quality of life ✓ Vermont Community Health ✓ Improves care coordination by wrapping services Team model had net savings of around the patient nearly $90 million in 2013 ✓ Extends healthcare beyond the walls of the ✓ Vermont ROI was larger in hospital and clinic to patient’s home commercial populations than in Medicaid ✓ Addresses physical, situational, emotional and social barriers to health ✓ May help reduce hospital readmissions and improve coordination of fragmented care ✓ Integration of a behavioral health professional into the provider team treatment approaches
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